Percentage of Patients With Pressure Ulcers/Pressure Injuries That Are New or Worsened
Identifying Attributes
Care Settings
Country
Publishing Organisation
Type of Quality Indicator
IOM Quality Dimension
Domain
Defining Attributes
Definition
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened.
Numerator
The numerator is the total number of IRF stays for which the IRF-PAI indicates one or more new or worsened Stage 2-4 pressure ulcer(s) or unstageable pressure ulcers due to slough/eschar, non-removable dressing/device, or deep tissue injury at discharge, compared to admission. 1) Stage 2 (M0300B1) - (M0300B2) > 0, OR 2) Stage 3 (M0300C1) - (M0300C2) > 0, OR 3) Stage 4 (M0300D1) - (M0300D2) > 0, OR 4) Unstageable – Non-removable dressing/device (M0300E1) - (M0300E2) > 0,OR 5) Unstageable – Slough and/or eschar (M0300F1) - (M0300F2) > 0,OR 6) Unstageable – Deep tissue injury (M0300G1) - (M0300G2) > 0.
Denominator
The total number of IRF stays with discharge date in the measure target period, which do not meet the exclusion criteria.
Exclusions
An IRF stay is excluded if: Data on new or worsened Stage 2, 3, 4, and unstageable pressure ulcers/injuries are missing at discharge: • (M0300B1 = [-] or M0300B2 = [-]) and (M0300C1 = [-] or M0300C2 = [-]) and (M0300D1= [-] or (M0300D2= [-]) and (M0300E1= [-] or M0300E2 = [-]) and (M0300F1= [-] or M0300F2 = [-]) and (M0300G1= [-] orM0300G2=[-]) The patient died during the IRF stay: • Item 44C = [0]
Use of Risk Adjustment
Risk Adjustments
Data for each covariate are derived from the IRF-PAI admission assessment data included in the target IRF stays. 1. Functional Mobility Admission Performance: Coding of dependent or substantial/maximal assistance for the functional mobility item Lying to Sitting on Side of Bed at admission: a. Covariate = [1] (yes) if GG0170C = [01, 02, 07, 09, 10, 88] ([01] = Dependent, [02] =Substantial/maximal assistance, [07] = Patient refused, [09] = Not applicable, [10] = Not attempted due to environmental limitations, [88] = Not attempted due to medical condition or safety concerns) b. Covariate = [0] (no) if GG0170C = [03, 04, 05, 06, -] ([03] =Partial/moderate assistance, [04] =Supervision or touching assistance, [05] =Setup or clean-up assistance, [06] = Independent, [-] =No response available) 2. Bowel Incontinence: Bowel Continence (H0400) at admission a. Covariate = [1] (yes) if H0400 = [1, 2, 3] ([1] = Occasionally incontinent, [2] = Frequently incontinent, [3] = Always incontinent) b. Covariate = [0] (no) if H0400 = [0, 9, -] ([0] = Always continent, [9] = Not rated, [-] = Not assessed/no information) 3. Peripheral Vascular Disease / Peripheral Arterial Disease or Diabetes Mellitus: a. Covariate = [1] (yes) if any of the following are true: i. I0900 = [1] (checked) ii. I2900 = [1] (checked) b. Covariate = [0] (no) if I0900 = [0, -] AND I2900 = [0, -] ([0] = No, [-] = No response available) 4. Low body mass index (BMI), based on height (25A) and weight(26A): a. Covariate = [1] (yes) if BMI ≥ [12.0] AND ≤ [19.0] b. Covariate = [0] (no) if BMI < [12.0] OR BMI > [19.0] c. Covariate = [0] (no) if Item 25A = [0, 00, -] OR Item26A = [-] ([-] = No response available) Where: BMI = (weight * 703 / height2) = ([Item 26A] * 703) / (Item 25A2) and the resulting value is rounded to one decimal place.* *To round off the percent value to one decimal place, if the digit in the second decimal place is greater than 5, add 1 to the digit in the first decimal place; otherwise, leave the digit in the first decimal place unchanged. Drop all the digits following the digit in the first decimal place.
Stratifications
Data Attributes
Type of Data Collection
Data Collection Methods
Effective on October 1, 2022, the IRF-PAI Version 4.0 is used to collect and submit assessment data for the IRF QRP.
Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Internet Quality Improvement and Evaluation System (iQIES).
Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
Source and Reference Attributes
Evidence Source
Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information. Accessed August 3, 2023. Available from: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/irf-quality-reporting/irf-quality-reporting-program-measures-information-.
Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual. Accessed August 3, 2023. Available from: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf.
Centers for Medicare & Medicaid Services (CMS), United States. Inpatient rehabilitation facilities - The Measures. Accessed August 3, 2023. Available from: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures.
Technical Specifications
Inpatient Rehabilitation Facility - Quality Reporting Program: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/irf-quality-reporting/irf-quality-reporting-program-measures-information-
Technical specifications: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf Measures: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures
Link to Measurement Tools
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)